The Kid’s Healthy Eating Plate was created as a fun and easy guide to encourage children to eat well and keep moving. The plate guidelines emphasize variety and quality in food choices.
The majority of the recommendations were pretty straightforward and mainstream:
The formula is simple: Fill half your plate (or lunch box) with colorful fruits or vegetables(aim for two to three different types). Fill about one-quarter with whole grains like whole grain pasta, brown rice, or quinoa, and the remaining quarter with healthy proteinslike beans, nuts, fish or chicken. Healthy fatsand a small amount of dairy (if desired) round out a tasty meal that will fuel an active, healthy lifestyle.
What caught my attention was the comment about dairy.
The dreaded words skim or low-fat did not appear in the sentence!
It would appear that a highly respect and mainstream source of nutritional advice is not making the typical (and scientifically unsupported ) recommendation to consume low fat or skim dairy products!
Indeed, if we look at their expanded comments on dairy they read:
Incorporating dairy (if desired). For example: unflavored milk, plain Greek yogurt, small amounts of cheese like cottage cheese, and string cheese.
No mention of fat content. Zip. Zero. To me, if you don’t put non fat low fat or skim next to the word diary it implies full fat.
Following their yogurt link we find no reference to preferentially consuming low fat yogurt despite the fact that the vast majority of yogurt sold in the US has been processed to remove healthy dairy fat, something the THCHSPH must be painfully aware of. (My wonderful MA Jenny’s husband, Frank, until very recently was unable to find full fat yogurt at Schnuck’s.)
As I pointed out here, a huge scam was foisted on Americans when allegedly healthy non fat yogurt filled with added sugar began to be promoted as a healthy treat.
It is almost as if the THTHCSPH has become agnostic about dairy fat and therefore is trying not to make recommendations.
Elsewhere on the THTHCSPH site however the old unwarranted advice to avoid dairy fat rears its ugly head. On a page devoted to calcium we read:
Many dairy products are high in saturated fats and a high saturated fat intake is a risk factor for heart disease”
Then this interesting (and ?ironic) observation:
And while it’s true that most dairy products are now available in fat-reduced or nonfat options, the saturated fat that’s removed from dairy products is inevitably consumed by someone, often in the form of premium ice cream, butter, or baked goods.
Strangely, it’s often the same people who purchase these higher fat products who also purchase the low-fat dairy products, so it’s not clear that they’re making great strides in cutting back on their saturated fat consumption.
The THTHCSPH seems conflicted, as well they should. They want to keep up the nutritional party line that they have been spouting for 30 years that all saturated fats are bad but they now realize that supporting non fat dairy products has likely worsened rather than improved the diet of millions of Americans.
N.B. The overall Kid’s healthy eating plate is not likely to be a favorite of kids and I disagree with some aspects of it.
Namely, I think it is fine to have red meat and processed meats in moderation and I wouldn’t push the pasta, rice, and bread.
On this fourth Thursday of November, 2015 the skeptical cardiologist would like to record some Thanksgiving thanks.
I’m thankful I’m not a turkey today.
I hear Americans consume 45 million turkeys on Thanksgiving, one sixth of the total during the year.
Americans have embraced turkeys nutritionally because they are low in saturated fat and provide lots of protein. Most nutritional advice suggests avoiding the dark meat and the skin, but I prefer to seek those portions out because they taste better and as I pointed out here last Thanksgiving, Up To Date, the major medical reference for physicians, now says “Don’t Worry About Saturated Fat Consumption.”
I’m thankful that dairy fat is good for you.
The eternal fiancee’ and I took a cooking class in New Orleans (New Orleans School of Cooking) recently, and butter seemed to be the basis for every dish we cooked: from dark roux in our gator sauce piquante’, to the blonde roux in the Louisiana meat pies.
When the teacher of the class, chef Austin, asked the students to introduce themselves, I told him I was the skeptical cardiologist and I was there to evaluate New Orleans dishes for my patients.
Chef Austin didn’t think I would be recommending the dishes to my patients, but I heartily endorsed them ( See here and here).
I’m thankful that cholesterol is no longer considered by the Dietary Guidelines for Americans Committee (DGAC) a nutrient of concern.
However, there is a backlash from the vegans on this revelation: the weirdly named Physicians Committee for Responsible Medicine (PCRM’s goal seems to be elimination of all animal testing and consumption, not responsible medicine) has erected billboards in Texas targeting the chairman of the House Agriculture Committee (K Michael Conoway (R-TX)).
The final guidelines have yet to be issued, but I’m betting on the egg industry over the vegans on this one, despite the billboards.
I’m thankful that studies continue to come out showing coffee is not bad for you.
This study, for example, followed 90 thousand Japanese for 19 years and found that the more coffee you drink, the lower your risk of dying-from cardiac, respiratory and cerebrovascular disease. Those consuming 3-4 cups/day were 25% less likely to die than those who never drank coffee.
-I’m thankful that correlation does not equal causation.
This means that I don’t have to stop eating bacon or beef brisket (assuming I am insensitive to global sustainability concerns). On the other hand, that association between higher coffee consumption and lower risk of dying over 19 years doesn’t mean that drinking more coffee is actually lowering the risk; but it’s certainly not increasing it.
Finally, I’m thankful that moderate alcohol consumption is good for your heart and I raise a toast of gratitude to patient patients, readers and correspondents.
Why is death from coronary heart disease declining in the US at the same time that obesity and diabetes rates are climbing?
Two editorials recently published in The Lancet show the widely varying opinions on the optimal diet for controlling obesity , diabetes and coronary heart disease that experts on nutrition, diabetes and heart disease hold.
The first paper contains what I would consider the saturated fat “traditionalist” viewpoint. This is a modification of the misguided concept that was foisted on the American public in the 1980s and resulted in the widespread consumption of industrially produced trans-fats and high sugar junk food that was considered heart healthy.
The traditionalists have shifted from condemning all fats to vilifying only saturated and trans fats. They would like to explain at least part of the reduction in coronary heart mortality as due to lower saturated fat consumption and the accompanying lowering of LDL (“bad”) cholesterol.
The SFA traditionalists fortunately are in decline and more and more in the last five years, prominent thinkers, researchers and scientists working on the connection between diet and the heart believe saturated fats are neutral but sugar and refined carbohydrates are harmful in the diet.
Darius Mozzafarian, a highly respected cardiologist and epidemiologist, who is dean of the School of Nutrition Science and Policy at Tufts, wrote the second editorial and is what I would term a saturated fatty acid (SFA) progressive.
He makes the following points which are extremely important to understand and which I have covered in previous posts. I’ve included his supporting references which can be accessed here.
Fat Doesn’t Make You Fat, Refined Starches And Sugar Do
"Foods rich in refined starches and sugars—not fats—seem to be the primary culprits for weight gain and, in turn, risk of type 2 diabetes. To blame dietary fats, or even all calories, is incorrect
Although any calorie is energetically equivalent for short-term weight loss, a food's long-term obesogenicity is modified by its complex effects on satiety, glucose–insulin responses, hepatic fat synthesis, adipocyte function, brain craving, the microbiome, and even metabolic expenditure Thus, foods rich in rapidly digestible, low-fibre carbohydrates promote long-term weight gain, whereas fruits, non-starchy vegetables, nuts, yoghurt, fish, and whole grains reduce long-term weight gain.1, 2, 3
Overall, increases in refined starches, sugars, and other ultraprocessed foods; advances in food industry marketing; decreasing physical activity and increasing urbanisation in developing nations; and possibly maternal–fetal influences and reduced sleep may be the main drivers of obesity and diabetes worldwide".
There Are Many Different Kinds of Saturated Fats With Markedly Different Health Effects: It Makes No Sense to Lump Them All Together
"SFAs are heterogeneous, ranging from six to 24 carbon atoms and having dissimilar biology. For example, palmitic acid (16:0) exhibits in vitro adverse metabolic effects, whereas medium-chain (6:0–12:0), odd-chain (15:0, 17:0), and very-long-chain (20:0–24:0) SFAs might have metabolic benefits.4 This biological and metabolic diversity belies the wisdom of grouping of SFAs based on a single common chemical characteristic—the absence of double bonds. Even for any single SFA, physiological effects are complex: eg, compared with carbohydrate, 16:0 raises blood LDL cholesterol, while simultaneously raising HDL cholesterol, reducing triglyceride-rich lipoproteins and remnants, and having no appreciable effect on apolipoprotein B, 5 the most salient LDL-related characteristic. Based on triglyceride-lowering effects, 16:0 could also reduce apolipoprotein CIII, an important modifier of cardiovascular effects of LDL and HDL cholesterol. SFAs also reduce concentrations of lipoprotein(a) ,6 an independent risk factor for coronary heart disease."
The Effects of Dietary Saturated Fats Depend on Complex Interactions With The Other Ingredients in Food
"Dietary SFAs are also obtained from diverse foods, including cheese, grain-based desserts, dairy desserts, chicken, processed meats, unprocessed red meat, milk, yoghurt, butter, vegetable oils, and nuts. Each food has, in addition to SFAs, many other ingredients and characteristics that modify the health effects of that food and perhaps even its fats. Judging the long-term health effects of foods or diets based on macronutrient composition is unsound, often creating paradoxical food choices and product formulations. Endogenous metabolism of SFAs provide further caution against oversimplified inference: for example, 14:0 and 16:0 in blood and tissues, where they are most relevant, are often synthesised endogenously from dietary carbohydrate and correlate more with intake of dietary starches and sugars than with intake of meats and dairy.4"
Dietary Saturated Fat Should Not Be a Target for Health Promotion
"These complexities clarify why total dietary SFA intake has little health effect or relevance as a target. Judging a food or an individual's diet as harmful because it contains more SFAs, or beneficial because it contains less, is intrinsically flawed. A wealth of high-quality cohort data show largely neutral cardiovascular and metabolic effects of overall SFA intake.7 Among meats, those highest in processing and sodium, rather than SFAs, are most strongly linked to coronary heart disease.7Conversely, higher intake of all red meats, irrespective of SFA content, increases risk of weight gain and type 2 diabetes; the risk of the latter may be linked to the iron content of meats.2, 8 Cheese, a leading source of SFAs, is actually linked to no difference in or reduced risk of coronary heart disease and type 2 diabetes.9, 10 Notably, based on correlations of SFA-rich food with other unhealthy lifestyle factors, residual confounding in these cohorts would lead to upward bias, causing overestimation of harms, not neutral effects or benefits. To summarise, these lines of evidence—no influence on apolipoprotein B, reductions in triglyceride-rich lipoproteins and lipoprotein(a), no relation of overall intake with coronary heart disease, and no observed cardiovascular harm for most major food sources—provide powerful and consistent evidence for absence of appreciable harms of SFAs."
Dietary Saturated Fats May Raise LDL cholesterol But This Is Not Important: Overall Effects On Obesity and Atherosclerosis Are What Matters
"a common mistake made by SFA traditionalists is to consider only slices of data—for example, effects of SFAs on LDL cholesterol but not their other complex effects on lipids and lipoproteins; selected ecological trends; and expedient nutrient contrasts. Reductions in blood cholesterol concentrations in Western countries are invoked, yet without systematic quantification of whether such declines are explained by changes in dietary SFAs. For example, whereas blood total cholesterol fell similarly in the USA and France between 1980 and 2000, changes in dietary fats explain only about 20% of the decline in the US and virtually none of that which occurred in France.11Changes in dietary fats11 simply cannot explain most of the reductions in blood cholesterol in Western countries—even less so in view of the increasing prevalence of obesity. Medication use also can explain only a small part of the observed global trends in blood cholesterol and blood pressure. Whether decreases in these parameters are caused by changes in fetal nutrition, the microbiome, or other unknown pathways remains unclear, thus highlighting a crucial and greatly underappreciated area for further investigation."
Dietary Saturated Fats Are Neutral For Coronary heart Disease Risk
Finally, SFA traditionalists often compare the effects of SFAs only with those of vegetable polyunsaturated fats, one of the healthiest macronutrients. Total SFAs, carbohydrate, protein, and monounsaturated fat each seem to be relatively neutral for coronary heart disease risk, likely due to the biological heterogeneity of nutrients and foods within these macronutrient categories.7Comparisons of any of these broad macronutrient categories with healthy vegetable fats would show harm,12 so why isolate SFAs? Indeed, compared with refined carbohydrates, SFAs seem to be beneficial.7
The overall evidence suggests that total SFAs are mostly neutral for health—neither a major nutrient of concern, nor a health-promoting priority for increased intake.
Focusing On Reducing Saturated Fats Leads To Unhealthy Dietary Choices
"Continued focus on modifying intake of SFAs as a single group is misleading—for instance, US schools ban whole milk but allow sugar-sweetened skim milk; industry promotes low-fat foods filled with refined grains and sugars; and policy makers censure healthy nut-rich snacks because of SFA content.13 "
It is extremely hard to change most people’s opinions on dietary fat.
My patients have been hearing the SFA traditionalist dogma for decades and thus it has become entrenched in their minds.
When I present to them the new progressive and science-based approach to fat and saturated fat some find it so mind boggling that they become skeptical of the skeptical cardiologist!
Hopefully, in the next few years, the progressive SFA recommendations will become the norm and maybe , some day in the not too distant future, the inexplicable recommendations for low-fat or non fat dairy will disappear.
As more data accumulates we may become SFA enthusiasts!
For another viewpoint (?from an SFA enthusiast) and a detailed description of both editorials see Axel Sigurdsson’s excellent post here.
The Paleo diet (primal/evolutionary) has become very popular in the last few years. Followers believe they are eating the way our stone age, or paleolithic, ancestors ate. Since our genes have not had time to evolve to match the drastic change in diet that occurred with the agricultural revolution, they argue, modern diets are making us sick and contributing to most of our chronic Western disease like atherosclerosis, diabetes and dementia.
True experts in evolutionary science have questioned most of the theoretical underpinnings of the Paleo movement. Marlene Zuk, an evolutionary biologist, has written an excellent critique in her recently published book “Paleofantasies: What Evolution Really Tells Us About Sex, Diet and How We Live.”
Dr. Zuk points out that there likely was no one single hunter-gatherer diet and that we have a very limited understanding of exactly what that diet consisted of. She also makes the point that this concept that at some point in the past, humans were perfectly adapted to their environment, is not true.
The Milk Paleofantasy
Although the Paleo movement is not monolithic on the topic, some of its leading figures are vehemently opposed to milk consumption.
For example, Loren Cordain (whose web site states that he is “widely acknowledged as one of the world’s leading experts on the natural human diet of our Stone Age ancestors”), has nothing but bad things to say about dairy and milk consumption. Cordain has a Ph.D in “health” and is quite a prolific author, having written “The Paleo Cure For Acne” (spoiler alert: the cure involves not drinking milk).
One major problem with the paleo concept of diet is the assumption that our genetic makeup has not changed or evolved over the last 10000 years.
It turns out that we are not stuck with the same genome of our caveman ancestors and that our ability to tolerate milk confirms this.
The Evolution of Lactose Tolerance
The main sugar in milk from all mammals is lactose. The ability to digest lactose depends on having the enzyme lactase present in the lining of the intestinal tract. All mammals at birth have lactase, but as they age, lactase production is reduced by around 90%. This loss of lactase leads to lactose intolerance.
Lactose that is not digested ends up being fermented by bacteria in the large intestines. This fermentation produces methane, hydrogen gases and other by-products, resulting in bloating, abdominal pain, and diarrhea.
Around 10-20,000 years ago, a mutation in the gene that controls production of lactase resulted in lactase persistence. Some of our paleolithic ancestors began noticing that they were lactose tolerant and could drink the milk of cattle that they had domesticated.
As Zuk writes:
Beginning about 7000 years ago, DNA studies of ancient bones reveal that there was a progressive increase in the frequency of lactase persistence. Increase in a genes frequency tends to correspond with a survival advantage suggesting that the ability to consume dairy prolonged lives.
Lactase persistence is present only in about 35% of the world’s population. It is common in Scandinavia and parts of Africa and the Middle East and about 90% of Americans have it.
The rapid increase in the dominant gene for lactase persistence in humans suggests that the Paleo concept of a genome stuck in the stone age is incorrect.
Stumbling onto a heart-healthy diet using Paleofantasies
Despite the lack of scientific support for the basic theories underpinning the movement, I do think the Paleo diet has some good points. For the most part, this is going to be a low-carb diet. Other areas I can agree with them on are:
A year ago one of my patients began experiencing chest pain when he walked up hills. Subsequent evaluation revealed that atherosclerotic plaque (95% narrowing of a major coronary artery ) was severely reducing the blood flow to his heart muscle and was the cause of his chest pain. When this blockage was opened up with a stent he no longer had the pain.
Along with other medications (aspirin and plavix to keep his stent open) I had him start atorvastatin, the generic version of Lipitor, a powerful statin drug that has been shown to prevent progression of atherosclerotic plaque and thereby reduce subsequent heart attacks, strokes and death in patients like him
I saw him in the office the other day in follow up and he was feeling great . He asked me “Doc I read your post yesterday.s Since you say that cholesterol in the diet doesn’t matter anymore, does that mean I don’t have to take my cholesterol drug anymore.?”
His question gets at the heart of the “diet-heart hypothesis”. The concept that dietary modification, with reduction of cholesterol and fat consumption can reduce coronary heart disease.
The science supporting this hypothesis has never been strong but the concept was foisted on the American public and was widely believed. It was accepted I would say because it has a beautiful simplicity which can be summarized as follows:
“If you eat cholesterol and fat it will enter your blood stream and raise cholesterol levels. This excess cholesterol will then deposit in your arteries, creating fatty plaque , clogging them and leading to a heart attack.”
This concept was really easy to grasp and simplified the public health recommendations.
However, cholesterol blood levels are determined more by cholesterol synthesized in the liver and predicting how dietary modifications will effect these levels is not easy.
Since the public has had the diet-heart hypothesis fed to them for decades and given its beautiful simplicity it is hard to reverse this dogma. My patient’s question reflects a natural concern that if science/doctors got this crucial question so wrong, is everything we know about cholesterol treatment and heart disease wrong?
In other words, are doctors promoting a great cholesterol hoax?
Evidence Strongly Supports Statins in Secondary Prevention
For my patient the science supporting taking a cholesterol-lowering statin drug is very solid. There are multiple excellent studies showing that in patients with established coronary artery disease taking a statin drug substantially reduces their risk of heart attack and dying.
These studies are the kind that provide the most robust proof: randomized, prospective and blinded.
When cardiologists rate the strength of evidence for a certain treatment (as done for lifestyle intervention here) we use a system that categorizes the evidence as Level A, B, or C quality.
LeveleA quality (or strong) evidence consists of multiple,large, well-done, randomized trials such as exist for statins in patients with coronary heart disease.
Level B Evidence comes from a single randomized trial or nonrandomized studies.
Level C evidence is the weakest and comes from “consensus opinion of experts, case studies or standard of care.”
When treatment recommendations are based on Level C evidence they are often reversed as more solid data is obtained. Level A recommendations almost always hold up over time.
The level of evidence supporting restricting dietary cholesterol and fat to reduce heart attacks and strokes has always been at or below Level C and now it is clear that it is insufficient and should be taken out of guideline recommendations.
Evidence Strongly Supports Atherogenic Cholesterol is Related to Coronary Heart Disease
There are other lines of evidence that strongly support the concept that LDL cholesterol (bad cholesterol) or an atherogenic form of LDL cholesterol is strongly related to the development of atherosclerosis. If you are born with really high levels you are at very high risk for coronary heart disease, conversely if you are born with mutations that cause extremely low levels you are highly unlikely to get coronary heart disease.
Thus, the cholesterol hypothesis as it relates to heart disease is very much till intact although the diet-heart hypothesis is not.
Conflating the Diet-Heart Hypothesis and the Cholesterol Hypothesis
There is an abundance of misinformation on the internet that tries to conflate these two concepts. Sites with titles like “The Great Cholesterol Lie” , “The” Cholesterol Hoax”, The Cholesterol Scam” abound .
These sites proclaim that cholesterol is a vital component of cell membranes (it is) and that any attempt by diet or drugs to lower levels will result in severe side effects with no benefit
Doctors, according to these types of sites, in collusion with Big Pharma, have inflated the benefits of statin drugs and overlooked the side effects in the name of profit. Often, a “natural” alternative to statins is promoted. In all cases a book is promoted.
The Great Cholesterol Truths
It’s unfortunate that nutritional guidelines have promoted restriction of cholesterol and fat for so long. These guidelines (like most of nutritional science) were based on flawed observational studies. They should not have been made public policy without more consensus from the scientific community. The good news is that ultimately the truth prevails when enough good scientific studies are done.
It is right to question the flimsy foundation of nutritional recommendations on diet and heart disease but the evidence for statin benefits in patients with established coronary heart disease is rock solid.
Hopefully, the less long-winded explanation I provided my patient in the office will persuade him to keep on taking his atorvastatin pills while simultaneously allowing him to eat eggs, shrimp and full fat dairy without guilt.
Since I’ve been utilizing coronary calcium CT scans to detect early atherosclerotic plaque (see here) in my patients, I have frequently been asked about the relationship between calcium supplements and heart attack risk.
For example, Mrs. Jones has just found out that she has a very high calcium score and that it reflects the amount of atherosclerotic plaque lining and potentially clogging the coronary arteries to her heart. She has also been taking calcium and Vitamin D supplements recommended to her to prevent bone thinning and fractures in the future.
Did all that extra calcium she was consuming end up depositing in her coronary arteries, thus increasing her risk of heart disease?
This is a complex and not fully settled issue, however, there is enough evidence to suggest that we be cautious about calcium supplements.
A recent meta-analysis (Bolland MJ, Avenell A, Baron JA, Grey A, MacLennan GS, Gamble GD, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691) of cardiovascular events in randomized, placebo controlled trials of calcium supplements (without vitamin D co-administration) showed that calcium supplements significantly increased the risk of myocardial infarction by 31% in five trials involving 8151 participants.
A recent meta-analysis of trials involving calcium and Vitamin D supplements found a similar increased risk of cardiovascular disease in the subjects randomized to taking calcium and Vitamin D.
These authors concluded
“in our analysis, treating 1000 patients with calcium or calcium and vitamin D for five years would cause an additional six myocardial infarctions or strokes (number needed to harm of 178) and prevent only three fractures (number needed to treat of 302”
How Might Calcium Supplements Increase Cardiovascular Risks?
Calcium supplements acutely and chronically increase serum calcium concentration. Higher calcium levels are associated with more carotid artery plaque, aortic calcification, and a higher incidence of heart attack and death.
Just like atherosclerosis, the process of calcium deposition into the arteries is very complex. Higher calcium levels could alter certain regulators of the process, such as fetuin A, pyrophosphate and bone morphogenic protein-7 or bind to calcium receptors on vascular smooth muscle cells lining the arteries
Higher calcium levels may also promote clot formation.
Bone Fracture versus Heart Attack
The informed doctor would have to tell Mrs. Jones that her calcium supplements may have contributed to her advanced coronary calcium and raised her risk of heart attack and stroke.
As with all medications, she and her doctor are going to have to discuss the relative risks and benefits.
If she has great concerns about fractures and has very low bone mineral bone density (osteoporosis) along with no family history of premature heart disease then the calcium supplementation may be appropriate.
Conversely, if she has high risk factors for coronary heart disease and/or a strong family history of premature coronary heart disease and only slightly low bone mineral density, avoiding the calcium supplements would be appropriate.
Preventing Fractures and Heart Attacks
It’s best to get calcium from the foods we eat rather than a sudden concentrated load of a supplement. Full fat dairy products like yogurt and cheese are heart healthy (see here and here) and they are an excellent source of calcium.
Weight-bearing exercise (such as running/jogging/hiking) and strength-building exercise (lifting weights, resistance machines, etc.) are also important for strengthening bones.
Thus, eating full fat dairy and aerobic exercise will help prevent both a fracture and a heart attack.
Despite mounting evidence to the contrary, mainstream nutritional guidelines have, for the last 30 years, instructed Americans to reduce fat and, more specifically, saturated fat in their diets.
As I have written here and here, that advice is not supported by the bulk of evidence and is being challenged. Despite this, the USDA guidelines and the American Heart Association guidelines continue to recommend reducing fat intake.
On October 26, 2014 a highly respected online resource called UpToDate changed its recommendations in this area. I became aware of this when I found an outstanding blog post by Dr. Axel Sigurdsson. Dr. Sigurdsson is a cardiologist and the former president of the Icelandic Cardiac Society who writes a blog called Doc’s Opinion; his recent post is titled: “About Heart Disease, Nutrition, Healthy Lifestyle and Prevention of Disease.”
UpToDate is by far the most commonly utilized online clinical decision resource in the world. A recent paper surveyed physicians and found that
the 4 most frequently used resources were online journals (46%), PubMed/MEDLINE (42%), UpToDate(40%), and online books (30%). The overall rating for UpToDate was high due to the large proportion of residents who reported using this resource (77%).
My hospital pays for a subscription to UpToDate and the medical staff and residents (doctors in training) use it very frequently to access the latest information on preventing, diagnosing and treating diseases. Hopefully, since the residents represent the future of medicine, these changed dietary recommendations will become more widespread and become the dominant nutritional message to the public.
“Although it is known that there is a continuous graded relationship between serum cholesterol concentration and coronary heart disease (CHD), and that dietary intake of saturated fats raises total serum cholesterol, a 2014 meta-analysis of prospective observational studies found no association between intake of saturated fat and risk for CHD.
The meta-analysis also found no relationship between monounsaturated fat intake and CHD, but suggested a reduction in CHD with higher intake of omega-3 polyunsaturated fats; a benefit with omega-6 polyunsaturated fats remains uncertain.
Given these results, we no longer suggest avoiding saturated fats per se, although many foods high in saturated fats are less healthy than foods containing lower levels.
In particular, we no longer feel there is substantial evidence for choosing dairy products based on low-fat content (such as choosing skim milk in preference to higher fat milk). We continue to advise reducing intake of trans fatty acids.”
I’m particularly happy to see this change with respect to dairy products because I think the switch to non or low fat diary has been deleterious to Americans’ health and is not supported by data.
As Dr. Sigurdsson observes:
Today, blaming the rising incidence of coronary heart disease 40-50 years ago on the intake of red meat, whole-fat milk, cheese, cream, butter and eggs appears naive at best.
To condemn one macronutrient and suggest it be replaced with another, without having any scientific evidence that such and intervention is helpful, would today be considered careless and irresponsible.
Sticking with the same conclusion for 40 years, despite abundant contradictory evidence is shocking and hard to understand. Hopefully, UpToDate’s recent reconsideration of the issue is a sign that the tide is turning.
Of course, there’s no reason to promote high consumption of saturated fats and surely there will often be healthier options. However, it’s time we stop telling people that avoiding saturated fats may protect them from heart disease. Why should we say such a thing if it’s not supported by evidence?
It will be interesting to see how public authorities such as the American Heart Association will react to recent scientific evidence on the proposed link between saturated fats and coronary artery disease. Will we see a change in the forthcoming 2015 version of The Dietary Guidelines for Americans?
Will their approach be evidence-based or not? Will they accept that red meat, whole-fat milk, cheese, cream, butter and eggs can be a part of a healthy diet? Will they reconsider their recommendations as UpToDate has now officially done? Only time will tell.
A number of readers of The Skeptical Cardiologist have pointed out to me that Time Magazine’s latest issue has a picture of butter on the cover with the headline “Eat Butter. Scientists labeled fat the enemy. Why they were wrong.”
The lead article summarizes a lot of the evidence I have been writing about which suggests that saturated fat has been inappropriately vilified (here) and that added sugar and processed food may be the real root cause of the obesity epidemic (here).
It is well-written and reasonably balanced and has some catchy graphics. It doesn’t really specifically address issues with dairy fat or butter as the title implies. I have defended high fat dairy in numerous posts over the past two years.
Hopefully this article in a well-respected mainstream newsmagazine will help correct the misinformation about diet and nutrition that has become entrenched in the consciousness of Americans.
Ah Cheese. A most wondrous and diverse real food. Of the thousands of delightful varieties, let us consider Wensleydale, the 33rd type of cheese requested by John Cleese of Ye Olde Cheese Emporium proprietor, Henry Wensleydale (Purveyor of Fine Cheese to the Gentry and the Poverty Stricken Too) in the Monty Python sketch, Cheese Shop.
The cheese I have in front of me from Wensleydale creamery (which owes its continued existence to being the favorite cheese of Wallace (of Wallace and Gromit fame)) lists the following ingredients:
pasteurized cow’s milk
annato (a natural coloring that gives cheese and other foods a bright orange hue. It comes from the Bixa orellana, a tropical plant commonly known as achiote or lipstick tree (from one of its uses))
Other than annato, the above ingredients are components of all cheese and signify that it is a non processed, nonindustrial product.
A 1 oz serving of this cheese (28 grams), like cheddar cheese (“the single most popular cheese in the world”), provides 110 calories, 80 of which are from fat (9 grams total fat, 6 grams saturated fat), 25 grams of cholesterol, 170 mg of salt and around 200 mg of calcium.
For the last 40 years, Americans have been mistakenly advised that all saturated fat in the food is bad and contributes to heart disease. Since cheese contains such a high proportion of saturated fat, it has also been targeted. Dietary recommendations suggest limiting real cheese consumption and switching to low-fat cheese.
This concept is not supported by any recent analysis of data, and as I’ve pointed out in a previous post, saturated fat does not contribute to obesity, nor is it clearly associated with increased heart disease risk. There are many different saturated fats and they have varying effects on putative causes of heart disease such as bad/good cholesterol and inflammation. In addition, the milieu in which the fats are consumed plays a huge role in how they effect the body.
Cheese vary widely in taste, texture and color and the final ingredients depend on a host of different factors including:
the type of animal milk used
the the diet of the animal
the amount of butterfat
whether the product is pasteurized or not
the strain of bacteria active in the cheese
the strain of mold active in the cheese
As a result the bioactive ingredients in cheese will vary from type to type.
Recent scientific reviews of the topic note that dairy products such as cheese do not exert the negative effects on blood lipids as predicted solely by the content of saturated fat. Calcium and other bioactive components may modify the effects on LDL cholesterol and triglycerides.
In addition, we now know that the effect of diet on a single biomarker is insufficient evidence to assess CAD risk; a combination of multiple biomarkers and epidemiologic evidence using clinical endpoints is needed to substantiate the effects of diet on CAD risk.
Some points to consider in why dairy and cheese in particular are healthy:
Blood pressure lowering effects. Calcium is thought to be one of the main nutrients responsible for the impact of dairy products on blood pressure. Other minerals such as magnesium, phosphate and potassium may also play a role. Casein and whey proteins are a rich source of specific bioactive peptides that have an angiotensin-I-converting enzyme inhibitory effect, a key process in blood pressure control. Studies have also suggested that certain peptides derived from milk proteins may modulate endothelin-1 release by endothelial cells, thereby partly explaining the anti-hypertensive effect of milk proteins.
Inflammation and oxidative stress reduction. These are key factors in the development of atherosclerosis and subsequent heart disease and stroke. Recent animal and human studies suggest that dairy components including calcium and or its unique proteins, the peptides they release, the phospholipids associated with milk fat or the stimulation of HDL by lipids themselves, may suppress adipose tissue oxidative and inflammatory response.
Government and health organization nutritional guidelines have had a huge and harmful impact on what the food industry presents to Americans to eat. The emphasis on reducing animal fats in food led to the creation of foods laden with processed vegetable oils containing harmful trans-fatty acids. This mistake has been recognized and corrected, but the overall unsupported concept of replacing naturally occurring saturated fats with processed carbohydrates and sugar is ongoing and arguably the root of the obesity epidemic in America.
Converting mistaken nutritional guidelines into law
The USDA in 2012 following an act of Congress stimulated by Michelle Obama, changed the standards for the national school lunch and breakfast guidelines, for the first time in 15 years.
The law was intended to increase consumption of fruits, vegetables, whole grains and promote the consumption of low-fat or nonfat milk. It seemed like a good idea and likely to counter increasing obesity in children. However, the original recommendations were modified by Congress, due to heavy food industry lobbying, to allow the small amount of tomato paste in pizza to qualify as a vegetable.
Unfortunately, the food industry has responded by providing products which meet the government’s criteria for healthy lunches, but in actuality are less healthy.
Dominos Pizza, as a recent New York Times article pointed out, is now providing a specially modified pizza to schools which is unavailable in their regular stores. Their so-called “Revolution in School Pizza” is a…
line of delicious, nutritious pizzas created specifically for schools delivered hot and fresh from your local Domino’s Pizza store. Domino’s Pizza Smart Slice is the nutritious food that kids will actually EAT and LOVE!
This pizza, in contrast to the pizza sold in Domino’s stores, utilizes a “lite” Mozarella cheese to cut fat content, a pepperoni with lower sodium and fat content, and a crust that contains 51% whole grain flour.
This “smart slice” replaces dairy fat with carbohydrates; there is no evidence that this will improve obesity rate or reduce heart disease In fact, this change may lead to less satiety and a tendency for the children to want to snack on further carbohydrate or sugar-laden products when they get home. Furthermore, as critics have suggested, it may promote the consumption of “unhealthy” versions of pizza that are sold in stores.
If we are going to make laws that promote healthy eating, we have to be absolutely certain that they are supported by scientific evidence. These School Lunch Program Standards are an example of how getting the science wrong or getting ahead of the science can lead to worse outcomes than if there were no laws regulating school diets.
Hopefully, you will continue to consume real full-fat cheese without concerns that cheese is “artery-clogging” and you will be more successful in obtaining the “fermented curd” than John Cleese’s Mr. Mousebender was below:
Many of my patients believe that coffee is bad for them. I’m not sure where this belief comes from; perhaps the general belief that anything that they really like and are potentially addicted to cannot be healthy.
It’s not uncommon for a patient to tell me after a heart attack that they have “really cleaned up their act” and have stopped drinking alcohol and cut back on coffee. They seem disappointed when I tell them that moderate alcohol consumption and coffee consumption are heart healthy behaviors.
In contrast to what the public believes, the scientific evidence very consistently suggests that drinking coffee is associated with living longer and having less heart attacks and strokes. Multiple publications in major cardiology journals in the last few years have confirmed this.
You can read the details here and here. The bottom line is that higher levels of coffee consumption (>1 cup per day in the US and >2 cups per day in Europe) are NOTassociated with:
Hypertension (if you are a habitual consumer)
Higher total or bad cholesterol (unless you consume unfiltered coffee like Turkish, Greek or French Press types, which allow a fair amount of the cholesterol-raising diterpenes into the brew)
Increase in dangerous (atrial fibrillation/ventricular tachycardia) or benign (premature ventricular or supra-ventricular contractions) irregularities in heart rhythm
Higher levels of coffee consumption compared to no or lower levels IS associated with:
lower risk of Type 2 Diabetes
lower risk of dying, more specifically lower mortality from cardiovascular disease
So, if you like coffee and it makes you feel good, drink it without guilt, there is nothing to suggest it is hurting your cardiovascular health. It’s a real food. These tend to be good for you.
Making Coffee Unhealthy: Dessert as Stealth Food
People have always added things to coffee – cream, half and half, milk, skim milk, sugar, artificial sweeteners. The coffee data doesn’t reveal to us what the consequences of these additions are, but given the consistent positive health associations of coffee, they must have had a minor effect.
However, in the last 20 years, the food industry, led by the behemoth Starbucks (which controls 1/3 of the coffee served in the US and has 11,000 stores and growing) has turned coffee into a stealth dessert. Starbucks offers the consumer (by their own admission) 87,000 different choices of coffee drinks.
A basic coffee house drink is a latte’. This consists of one or more shots of espresso combined with steamed milk (skim, 2% or whole) and topped with foam. According to Starbucks, the 16 ounce, medium (I refuse to use their size terminology), cafe latte’ made with 2% milk, contains 17 grams of sugar and 7 grams of fat, yielding a reasonable 190 calories. Those who drink these should understand that they are consuming a glass of milk, plus coffee. Dairy products have consistently been associated with lower cardiovascular risk. They would arguably be better off consuming a whole milk (11 grams fat, 16 grams sugar, 220 calories) latte’ as I’ve pointed out in previous blogs here and here.
Most of the latte’s consumed at Starbucks aren’t plain latte’s, however; they are nightmares of added sugar. Let’s take the Cinnamon Dolce Latte’: (A complete nutritional breakdown is available from Starbucks’ website (I do congratulate Starbucks for finally capitulating and presenting nutritional data on their products at stores, allowing the public to draw back the curtain on the Starbucks Oz. Their website provides a cool way to compare your drink with whole/2%/skim/soy milk or with and without whipped cream)) It contains 38 grams of sugar, 6 grams of fat, and 11 grams of protein, yielding 260 calories, 152 of which are coming from sugar. That’s 22 grams more sugar, compared to their unadulterated latte’. (There must be an internet site devoted to promoting the health benefits of cinnamon since I hear about them so often from my patients but this claim is not evidence-based)
My 17 year old daughter’s drink of choice at Starbucks is the Mocha Frappuccino® Blended Beverage, which, according to Starbucks, is “Coffee with rich mocha-flavored sauce, blended with milk and ice. Topped with sweetened whipped cream.” It contains 60 grams of sugar, 15 grams of fat and has 400 calories.
Such concoctions have no right to consider themselves coffee, they should be labeled as a sugar-laden dessert that happens to have some coffee in it. To give some perspective, the typical 20 ounce soda contains 40 grams of sugar (the equivalent of 10 packs of sugar). Starbucks has added 44 grams of sugar to coffee and milk in order to draw children, teens and unsuspecting adults to consume more “coffee.”
There is growing evidence that sugar, not fat, is the major toxin in our diet. The misguided concept that cutting fat in the diet and replacing it with anything, including sugar, will reduce cardiovascular disease is gradually being rolled back. Nutritional advocates are now zeroing in on appropriate targets like sugary beverages.
It’s sad that Starbucks, which started out making a good, real product that was actually good for you, has morphed into an international, growth-obsessed, behemoth that is pumping billions of grams of added sugar into our stomachs.
But, as the significant other of the skeptical cardiologist (SOSC) often muses, people are always looking for new ways to con themselves into thinking they are eating/drinking something healthy, when in fact, they are just eating/drinking cleverly disguised desserts. Starbucks has made a huge success for themselves by providing people what they want: a way to kid themselves.